In reality the answer is ... they spend huge sums on BOTH R&D and sales & marketing.

Keep in mind that R&D expenses get favorable tax treatment so companies have a big incentive to shift as many costs as possible into the R&D category. That can make R&D quite a bit larger than it might otherwise be.

The company's annual 10-K filing with the SEC is fairly clear on total profits, total sales costs, and how all of that is divided.

As to Gen's point: it's not necessarily some great conspiracy: the ordinary R&D budget process does this too. When deciding what projects to fund a key, key component is potential Return on Investment, and treatments for chronic illnesses always look better than outright cures (since the revenue stops after cure!)

The obvious solution is to shorten the patent length for treatments of symptoms while leaving patent periods long for cures. That changes the R&D ROI analysis entirely and cures would look better for funding. Of course, it's hardly black & white to designate what falls in each category, but the point is that changing the profit potentials is a very good way to change corporate behavior here.

The other huge problem in the American medical system is cost-shifting. Nobody wants to pay their share, and hospitals shift huge amounts of cost to other groups. Worse, costs are shifted from those who can most afford onto those who can least afford it. Private individuals can easily pay 10x the actual going rates.

This summer a friend of mine moved to Mexico for a few months for the birth of his baby. He had excellent doctors and used top facilities, and paid a tenth of the amount the local US hospital charges. I think the difference was not so much "Mexico is cheap" but rather payment concepts: he paid the doctors cash before each visit and at delivery (*before* delivery!). No billing, no collection hassles, and the hospital has no reason to cost-shift. He paid his share and probably nobody else's.

Cash-in-Advance might not be the thing for the US, but a lot would be solved if each patient/insurer were required to pay at least actual costs of their treatment, and if doctors, hospitals and clinics were forbidden to cost-shift.